Issue: February 2021
Disclosures: Craig, Golper, Morfin, Schiller and Schreiber report no relevant financial disclosures.
February 16, 2021
7 min read
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Kidney community sets the stage for ‘home first’ approach to dialysis

Issue: February 2021
Disclosures: Craig, Golper, Morfin, Schiller and Schreiber report no relevant financial disclosures.
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When a person arrives at the emergency room of the University of California Davis Medical Center with an eGFR of less than 20 mL/min/1.73 m2, Jose Morfin, MD, and Maureen Craig, RN, MSN, CNN, APHN-BC, go to work.

“It’s not unusual for these patients to already be under our watchful eye at UC Davis Health and being followed by a nephrologist,” Morfin told Nephrology News & Issues. “The patient can see a sudden change in kidney function.

“But we also see patients who have not experienced helpful prevention strategies and end up with late-stage or advanced kidney disease.”

(from left) Maureen Craig, RN, MSN, CNN, APHN-BC, a clinical nurse specialist in nephrology at UC Davis Medical Center, and nephrologist Jose Morfin, MD, have had a high success rate in keeping emergent patients on home dialysis.

Source: Wayne T. Tilcock/© Regents of the University of California, Davis

Craig screens the patients, which includes a review of their home life, family support and whether there is substance abuse, to determine if the patient can manage home dialysis therapy.

The patient training and education program on emergent peritoneal dialysis at UC Davis in Sacramento has not only generated cases of new patients choosing home therapy, but it has also provided positive long-term results. Patients who suddenly face the need for dialysis can succeed at home and stay on the therapy, Morfin said.

“We want to say to these patients, ‘We believe this will give you better dialysis,’” Morfin said.

“I think, often times, we get caught up in saying, ‘We’re agnostic about treatment options. Everything is the same’ in terms of outcomes,” he said. “But it’s not the same. We think home first is a better choice.”

Kidney specialists who spoke with Nephrology News & Issues cautioned that conversations between the care team and patients with progressive kidney failure should first include transplantation, and then conservative care for some patients.

If a conservative management option or pre-emptive transplant is not a good fit, however, home dialysis should be the first choice of therapy, Martin Schreiber, MD, chief medical officer for home modalities at DaVita Kidney Care, told Nephrology News & Issues.

“Consistent with the [Trump administration] executive order and the [End-stage Renal Disease Treatment Choices] model, success will take a change in the thinking for renal replacement therapy such that home becomes the default option,” he said.

CMS promotes home dialysis

Martin Schreiber

Interest in home dialysis began in 1963 in the United States and in the United Kingdom as the patient population increased and hospitals did not have the funds to expand their programs. Charles Kirby, MD, a vascular surgeon, first suggested the idea in his 1961 presidential address at the American Society of Artificial Internal Organs Annual Meeting, saying: “Perhaps what we need is a home dialysis unit to be placed by the patient’s bedside, so that he can plug himself in for an 8-hour period once or twice a week.”

At its peak, close to 40% of patients were receiving dialysis therapy at home.

After Congress approved Medicare coverage for dialysis and kidney transplant in 1972, freestanding dialysis clinics opened up rapidly around the United States. Treatments became more efficient, as did dialysis machines. The introduction of peritoneal dialysis in the mid-1970s revived interest in home dialysis, reaching 16% in the mid-1990s. Most recently it has remained at around 12% of outpatient dialysis treatments in the United States.

One of the goals set by Advancing American Kidney Health includes having 80% of new patients starting renal replacement therapy (RRT) in 2025 either at home or have a functioning transplant. In the ESRD Treatment Choices Model demonstration, which began in January, CMS offers bonus payments to dialysis providers and to nephrologists when they increase the number of patients dialyzing at home.

“Physicians have a tremendous amount of responsibility in the vision for growing home dialysis, and we must continue to balance the need for progress with the needs of our patients every step of the way,” Schreiber said. “While home first is the ideal state–and we must educate and innovate to that end–it will not be the right therapy for every patient at every juncture.”

The task of convincing newly diagnosed patients with ESRD to accept the responsibilities of self-care is not easy. Craig faces that challenge in the emergency room – suddenly, patients must become an expert in using dialysis technology and being sensitized about things like peritonitis and ensuring adequate treatment. A strong training program and a clinical team that champions home dialysis makes a big difference, she said.

“In conversations with patients, they always seem surprised by the current event, whether it be fluid overload, high potassium or declining kidney function related to a heart or liver problem,” Craig said. “No one intends to go to the hospital. The human nervous system is just not that in tune with predicting decline.”

Improve market share

Even without the push from CMS initiatives to place more patients on home dialysis, providers have made efforts to improve on the low market share that home dialysis holds in the United States, which is lower than that of other countries. According to the 2020 annual data report of the U.S. Renal Data System, the number of prevalent patients with end-stage kidney disease who performed home dialysis at the end of 2018 was 68,986, an increase of 7.9% from 2017 and the highest rate of year-to-year growth since 2013.

“Between 2008 and 2018, the number of patients performing home dialysis more than doubled,” the report authors wrote (see Figure).

Dialysis providers Fresenius Kidney Care and DaVita Kidney Care have been major contributors to the surge. Fresenius bought home dialysis machine manufacturer NxStage Medical 2 years ago for $2 billion after NxStage launched its successful SystemOne portable dialysis machine. As a result of numerous educational and operational initiatives to prioritize home-centric modalities, Fresenius reported a 15% increase in home dialysis adoption in the past year and a 40% increase in the overall home hemodialysis population in 2020 compared to the previous year (click here to read an accompanying First Word).

Schreiber noted that since 2019, DaVita has seen a 30% increase in the share of new patients starting dialysis at home.

Dialysis provider Satellite Healthcare has one of the highest percentage of home patients in the United States.

“We are excited about the nationwide focus on home dialysis for all involved in ESKD care delivery – the patients, physicians and the providers,” Brigitte Schiller, MD, Satellite’s chief medical officer, told Nephrology News & Issues. “The Advancing American Kidney Health initiative strengthens the alignment of the various stakeholders which makes it more likely for a home first approach to be successful.”

However, Schiller said the model for expanding home dialysis needs to be different than what is in place now.

“In order to execute and scale home dialysis in the U.S., a model based on the clinical and psychosocial needs and economic reality of the patient needs to be developed,” she said. “The care model will rely on a different infrastructure and starts before dialysis is needed with education and assessment of the patient and family.

Home dialysis access for physicians and patients will need to be as easy as center dialysis is currently. That requires coordination and additional services that are suboptimal or missing – home assessment, supply delivery, timely training in possibly different locations, more support for patients and families in the beginning of home therapy and at times of risk, including after hospitalizations or care-giver issues, efficient and easy monitoring, and care coordination,” Schiller said.

One area of growth that will help coordinate the effort is improved technology.

“There will be new technology, including telehealth, telemonitoring, more user-friendly [home hemodialysis] HHD machines and [peritoneal dialysis] PD cyclers that will be critical to advance the home approach,” Schiller said. “But technology alone will not suffice. The biggest impact will likely require disruptive new care models.”

Schreiber agreed that a model for patient assessment and infrastructure for home should resemble that of in-center dialysis care. “We have developed many efficiencies with in-center [care] – designing the physical plant, developing staffing models. We need the same for home dialysis,” he said.

That might include something like a “geek squad” that goes into a home and evaluates the setting – everything from checking connectivity for telehealth application, reviewing family support, explaining the need for infection control practices and verifying adequate infrastructure, such as plumbing needs, storage space for supplies, etc., Schreiber said.

Improve physician education

More work within the kidney community also needs to be done to encourage nephrologists to take a home first approach. Thomas A. Golper, MD, FACP, who heads the home dialysis program at Vanderbilt Medical Center – where more than 40% of his patients are on home therapy – led a team of authors on a paper published in the American Journal of Kidney Diseases that outlined steps to increase the use of home therapies in the United States.

“The barriers to expansion of home dialysis in the United States are systematic and thus will require systematic solutions,” the authors wrote in the paper, published in 2011. “Many home dialysis centers facing these barriers are trying to find local ‘workaround’ solutions instead of a broad correction to the systematic components of the problem ... more attention to home dialysis is necessary as we face a worsening crisis involving a shortage of in-center dialysis nurses, an expanding end-stage kidney disease population and health care cost constraints. A collective effort is needed from the renal community to establish priorities as we endeavor to achieve the goal of increasing the prevalence of dialysis at home, where it belongs,” the authors wrote.

A decade later, many of the issues outlined in the study have not been resolved, Golper, who is chair of the Editorial Advisory Board for Nephrology News & Issues, said. “We have a lot of work to do.”

Still, there remains optimism among those interviewed for this article that a strategy to push home dialysis first among nephrologists and dialysis providers, coupled with government incentives, can make a difference.

“With a deliberate strategy supporting home dialysis, we expect this to be the best opportunity for meaningful change in ESKD care since 1973,” Schiller said.

“I encourage home because of Dorothy’s comment [from The Wizard of Oz],” Golper said. “There’s no place like home.’”